Académique Documents
Professionnel Documents
Culture Documents
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The Neuroscience of Mental Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Complexity of the Brain I: Structural . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Complexity of the Brain II: Neurochemical . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Complexity of the Brain III: Plasticity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Imaging the Brain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Overview of Etiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Biopsychosocial Model of Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Understanding Correlation, Causation, and Consequences . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Biological Influences on Mental Health and Mental Illness . . . . . . . . . . . . . . . . . . . . . . . . . . .
The Genetics of Behavior and Mental Illness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Infectious Influences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
PANDAS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Psychosocial Influences on Mental Health and Mental Illness . . . . . . . . . . . . . . . . . . . . . . . . . .
Psychodynamic Theories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Behaviorism and Social Learning Theory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
The Integrative Science of Mental Illness and Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Overview of Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
Definitions of Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
Risk Factors and Protective Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
Overview of Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Introduction to Range of Treatments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Psychotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Psychodynamic Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Behavior Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Humanistic Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Pharmacological Therapies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Mechanisms of Action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Complementary and Alternative Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Issues in Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Placebo Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Benefits and Risks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Gap Between Efficacy and Effectiveness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Barriers to Seeking Help . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Overview of Cultural Diversity and Mental Health Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Introduction to Cultural Diversity and Demographics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Coping Styles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Family and Community as Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Epidemiology and Utilization of Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
African Americans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Asian Americans/Pacific Islanders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Hispanic Americans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Native Americans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Barriers to the Receipt of Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Help-Seeking Behavior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Mistrust . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Stigma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Cost . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Clinician Bias . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Improving Treatment for Minority Groups . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Ethnopsychopharmacology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Minority-Oriented Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Cultural Competence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Rural Mental Health Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Overview of Recovery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
Introduction and Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
Impact of the Recovery Concept . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100
Mental Health and Mental Illness Across the Lifespan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
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brain is useless without the sculpting that environment,
experience, and thought itself provides. Thus the brain
is now known to be physically shaped by contributions
from our genes and our experience, working together.
This strengthens the view that mental disorders are both
caused and can be treated by biological and experiential
processes, working together. This understanding has
emerged from the breathtaking progress in modern
neuroscience that has begun to integrate knowledge
from biological and behavioral sciences.
An overview of mental illness follows the section
on modern integrative brain science. The section
highlights topics including symptoms, diagnosis,
epidemiology (i.e., research having to do with the
distribution and determinants of mental disorders in
population groups, including various racial and ethnic
minority groups), and cost, all of which are discussed
in greater and more pointed detail in the chapters that
follow. Etiology is the study of the origins and causes
of disease, and that section reviews research that is
seeking to define, with ever greater precision, the
causes of mental disorders. As will be seen, etiology
research examines fundamental biological, behavioral,
and sociocultural processes, as well as a necessarily
broad array of life events. The section on development
of temperament reveals how mental health science has
attempted over much of the past century to understand
how biological, psychological, and sociocultural factors
meld in health as well as in illness. The chapter then
reviews research approaches to the prevention and
treatment of mental disorders and provides an overview
of mental health services and their delivery. Final
sections cover the growing influence on the mental
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As befits the organ of the mind, the human brain is the
most complex structure ever investigated by our
science. The brain contains approximately 100 billion
nerve cells, or neurons, and many more supporting
cells, or glia. In and of themselves, the number of cells
1
Special thanks to Steven E. Hyman, M.D., Director, National Institute of Mental Health, and Gerald D. Fischbach, M.D., Director,
National Institute of Neurological Diseases and Stroke, for their contributions to this section.
32
33
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Table 2-1.
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Superimposed on this breathtaking structural
complexity is the chemical complexity of the brain. As
described above, electrical signals within neurons are
converted at synapses into chemical signals which then
elicit electrical signals on the other side of the synapse.
These chemical signals are molecules called
neurotransmitters. There are two major kinds of
molecules that serve the function of neurotransmitters:
small molecules, some quite well known, with names
such as dopamine, serotonin, or norepinephrine, and
larger molecules, which are essentially protein chains,
called peptides. These include the endogenous opiates,
Substance P, and corticotropin releasing factor (CRF),
among others. All told, there appear to be more than
100 different neurotransmitters in the brain (Table 2-1
contains a selected list).
Tachykinin
Substance P
Hypothalamic-releasing factors
Corticotropin-releasing hormone
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There are many exciting developments in brain science.
Of great relevance to the study of mental function and
mental illness is the ability to image the activity of the
living human brain with technologies developed in
recent decades, such as positron emission tomography
scanning or functional magnetic resonance imaging.
Such approaches can exploit surrogates of neuronal
firing such as blood flow and blood oxygenation to
provide maps of activity. As science learns more about
brain circuitry and learns more from cognitive and
affective neuroscience about how to activate and
examine the function of particular brain circuits,
differences between health and illness in the function
of particular circuits certainly will become evident. We
will be able to see the action of psychotropic drugs and,
perhaps most exciting, we will be able to see the impact
of that special kind of learning called psychotherapy,
which works after all because it works on the brain.
Different brain chemicals, brain receptors, and
brain structures will come up in the discussion of
particular illnesses throughout this document. This
section is meant to provide a panoramic, not a detailed,
introduction and also to provide certain overarching
lessons. When something is referred to as biological or
brain-based, that is not shorthand for saying it is
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Mental illness is a term rooted in history that refers
collectively to all of the diagnosable mental disorders.
Mental disorders are characterized by abnormalities in
cognition, emotion or mood, or the highest integrative
aspects of behavior, such as social interactions or
planning of future activities. These mental functions
are all mediated by the brain. It is, in fact, a core tenet
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Persons suffering from any of the severe mental
disorders present with a variety of symptoms that may
include inappropriate anxiety, disturbances of thought
and perception, dysregulation of mood, and cognitive
dysfunction. Many of these symptoms may be
relatively specific to a particular diagnosis or cultural
influence. For example, disturbances of thought and
perception (psychosis) are most commonly associated
with schizophrenia. Similarly, severe disturbances in
expression of affect and regulation of mood are most
commonly seen in depression and bipolar disorder.
However, it is not uncommon to see psychotic
symptoms in patients diagnosed with mood disorders or
to see mood-related symptoms in patients diagnosed
with schizophrenia. Symptoms associated with mood,
anxiety, thought process, or cognition may occur in any
patient at some point during his or her illness.
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Table 2-3.
Common manifestations of
schizophrenia
Positive Symptoms
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Agitation
Negative Symptoms
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Concrete thoughts
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The foregoing discussion has suggested that the
manifestations of mental disorders fall into a
number of distinct categories such as anxiety,
psychosis, mood disturbance, and cognitive
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Table 2-5.
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2
DSM-I (American Psychiatric Association, 1952), DSM-II
(American Psychiatric Association, 1968), DSM-III (American
Psychiatric Association, 1979), and DSM-III-R (American
Psychiatric Association, 1987).
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The current prevalence estimate is that about 20
percent of the U.S. population are affected by
mental disorders during a given year. This estimate
comes from two epidemiologic surveys: the
Epidemiologic Catchment Area (ECA) study of the
early 1980s and the National Comorbidity Survey
(NCS) of the early 1990s. Those surveys defined
mental illness according to the prevailing editions
of the Diagnostic and Statistical Manual of Mental
Disorders (i.e., DSM-III and DSM-III-R). The
surveys estimate that during a 1-year period, 22 to
23 percent of the U.S. adult populationor 44
million peoplehave diagnosable mental disorders,
according to reliable, established criteria. In
general, 19 percent of the adult U.S. population
have a mental disorder alone (in 1 year); 3 percent
have both mental and addictive disorders; and 6
percent have addictive disorders alone. 3
Consequently, about 28 to 30 percent of the
population have either a mental or addictive
disorder (Regier et al., 1993b; Kessler et al., 1994).
Table 2-6 summarizes the results synthesized from
these two large national surveys.
Individuals with co-occurring disorders (about
3 percent of the population in 1 year) are more
likely to experience a chronic course and to utilize
services than are those with either type of disorder
alone. Clinicians, program developers, and policymakers need to be aware of these high rates of
comorbidityabout 15 percent of those with a
mental disorder in 1 year (Regier et al., 1993a;
Kessler et al., 1996).
Based on data on functional impairment, it is
estimated that 9 percent of all U.S. adults have the
mental disorders listed in Table 2-6 and experience
some significant functional impairment (National
4
The term serious emotional disturbance is used in a variety of
Federal statutes in reference to children under the age of 18 with a
diagnosable mental health problem that severely disrupts their
ability to function socially, academically, and emotionally. The term
does not signify any particular diagnosis; rather, it is a legal term
that triggers a host of mandated services to meet the needs of these
children.
3
Although addictive disorders are included as mental disorders in
the DSM classification system, the ECA and NCS distinguish
between addictive disorders and (all other) mental disorders.
Epidemiologic data in this report follow that convention.
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Table 2-6. Best estimate 1-year prevalence rates based on ECA and NCS, ages 18%54
13.1
8.3
2.0
4.9
(1.5)*
1.6
2.4
(1.9)*
18.7
8.6
7.4
3.7
3.4
2.2
(0.9)*
3.6
16.4
8.3
2.0
4.9
3.4
1.6
2.4
3.6
7.1
6.5
5.3
1.6
1.1
0.6
11.1
10.1
8.9
2.5
1.3
0.2
7.1
6.5
5.3
1.6
1.1
0.6
Schizophrenia
Nonaffective Psychosis
Somatization
ASP
Anorexia Nervosa
Severe Cognitive
Impairment
1.3
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0.2
2.1
0.1
1.2
&
0.2
&
&
&
&
1.3
0.2
0.2
2.1
0.1
1.2
19.5
23.4
21.0
Any Disorder
*Numbers in parentheses indicate the prevalence of the disorder without any comorbidity. These rates were calculated using the NCS data for
GAD and PTSD, and the ECA data for OCD. The rates were not used in calculating the any anxiety disorder and any disorder totals for the ECA
and NCS columns. The unduplicated GAD and PTSD rates were added to the best estimate total for any anxiety disorder (3.3%) and any disorder
(1.5%).
**In developing best-estimate 1-year prevalence rates from the two studies, a conservative procedure was followed that had previously been used
in an independent scientific analysis comparing these two data sets (Andrews, 1995). For any mood disorder and any anxiety disorder, the lower
estimate of the two surveys was selected, which for these data was the ECA. The best estimate rates for the individual mood and anxiety disorders
were then chosen from the ECA only, in order to maintain the relationships between the individual disorders. For other disorders that were not
covered in both surveys, the available estimate was used.
Key to abbreviations: ECA, Epidemiologic Catchment Area; NCS, National Comorbidity Study; GAD, generalized anxiety disorder; OCD,
obsessive-compulsive disorder; PTSD, post-traumatic stress disorder; MD, major depression; ASP, antisocial personality disorder.
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Table 2-8.
13.0
6.2
10.3
2.0
20.9
11.4
Simple Phobia
7.3
Social Phobia
1.0
Agoraphobia
4.1
Panic Disorder
0.5
Obsessive-Compulsive
Disorder
1.5
4.4
3.8
3.7
Dysthymia
1.6
Bipolar I
0.2
Bipolar II
0.1
Schizophrenia
0.6
Somatization
0.3
0.0
Anorexia Nervosa
0.0
6.6
Any Disorder
19.8
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The epidemiology of mental disorders is somewhat
handicapped by the difficulty of identifying a
case of a mental disorder. Case is an
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The precise causes (etiology) of most mental
disorders are not known. But the key word in this
statement is precise. The precise causes of most
mental disordersor, indeed, of mental health
may not be known, but the broad forces that shape
them are known: these are biological, psychological, and social/cultural factors.
What is most important to reiterate is that the
causes of health and disease are generally viewed
as a product of the interplay or interaction between
biological, psychological, and sociocultural factors.
This is true for all health and illness, including
mental health and mental illness. For instance,
diabetes and schizophrenia alike are viewed as the
result of interactions between biological,
psychological, and sociocultural influences. With
these disorders, a biological predisposition is
necessary but not sufficient to explain their
occurrence (Barondes, 1993). For other disorders,
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The modern view that many factors interact to
produce disease may be attributed to the seminal
work of George L. Engel, who in 1977 put forward
the Biopsychosocial Model of Disease (Engel,
1977). Engels model is a framework, rather than a
set of detailed hypotheses, for understanding health
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Any discussion of the etiology of mental health and
mental illness needs to distinguish three key terms:
correlation, causation, and consequences. These
terms are often confused. All too frequently a
biological change in the brain (a lesion) is
purported to be the cause of a mental disorder,
based on finding an association between the lesion
and a mental disorder. The fact is that any simple
associationor correlationcannot and does not,
by itself, mean causation. The lesion could be a
correlate, a cause of, or an effect of the mental
disorder.
When researchers begin to tease apart etiology,
they usually start by noticing correlations. A
correlation is an association or linkage of two (or
more) events. A correlation simply means that the
events are linked in some way. Finding a
correlation between stressful life events and
depression would prompt more research on
causation. Does stress cause depression? Does
depression cause stress? Or are they both caused by
an unidentified factor? These would be the
questions guiding research. But, with correlational
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There are far-reaching biological and physical
influences on mental health and mental illness. The
major categories are genes, infections, physical
trauma, nutrition, hormones, and toxins (e.g., lead).
Examples have been noted throughout Chapter 1
and earlier in this chapter. This section focuses on
the first two categoriesgenes and infectionsfor
these are among the most exciting and intensive
areas of research relating to biological influences
on mental health and mental illness.
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Other types of information used to establish cause and effect
relationships are the strength and consistency of the association,
time sequence information, dose-response relationships, and
disappearance of the effect when the cause is removed.
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Anxiety and depression may in some cases be caused by hormonal
changes related to the tumor itself.
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This chapter thus far has highlighted some of the
psychosocial influences on mental health and
mental illness. Stressful life events, affect (mood
and level of arousal), personality, and gender are
prominent psychological influences. Social
influences include parents, socioeconomic status,
racial, cultural, and religious background, and
interpersonal relationships. These psychosocial
influences, taken individually or together, are
integrated into many chapters of this report in
discussions of epidemiology, etiology, risk factors,
barriers to treatment, and facilitators to recovery.
Since these psychosocial influences are familiar
to the general reader, detailed description of each
is beyond the scope of this section (with the
exception of cultural influences, which are
discussed in the Overview of Cultural Diversity and
Mental Health Services section). Instead, this
section summarizes the sweeping theories of
individual behavior and personality that inspired a
vast body of psychosocial research: psychodynamic
theories, behaviorism, and social learning theories.
The therapeutic strategies that arose from these
theories, and modifications necessary to make them
relevant to the changing demography of the U.S.
population, are discussed in a later section,
Overview of Treatment.
3$1'$6
In the late 1980s, it was discovered that some
children with obsessive-compulsive disorder (OCD)
experienced a sudden onset of symptoms soon after
a streptococcal pharyngitis (Garvey et al., 1998).
The symptoms were classic for OCDconcerns
about contamination, spitting compulsions, and
extremely excessive hoardingbut the abrupt onset
was unusual. Further study of these children led to
the identification of a new classification of OCD
called PANDAS. This acronym stands for pediatric
autoimmune neuropsychiatric disorders associated
with streptococcal infection. PANDAS are distinct
from classic cases of OCD because of their
episodic clinical course marked by sudden
symptom exacerbation linked to streptococcal
infection, among other unique features. The
exacerbation of symptoms is correlated with a rise
in levels of antibodies that the child produces to
fight the strep infection. Consequently, researchers
proposed that PANDAS are caused by antibodies
against the strep infection that also manage to
attack the basal ganglia region of the childs brain
(Garvey et al., 1998). In other words, the strep
infection triggers the childs immune system to
develop antibodies, which, in turn, may attack the
childs brain, leading to obsessive and compulsive
behaviors. Under this proposal, the strep infection
does not directly induce the condition; rather, it
3V\FKRG\QDPLF 7KHRULHV
55
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How we come to be the way we are is through the
process of development. Generally defined as the
lifelong process of growth, maturation, and change,
development is the product of the elaborate
interplay of biological, psychological, and social
influences. By studying development, researchers
hope to uncover the origins of both mental health
and mental illness.
This section elaborates and extends concepts
introduced above regarding the fundamental
workings of the brain at different developmental
stages. It then proceeds to explain several seminal
theories of development pioneered by Jean Piaget,
Erik Erikson, and John Bowlby. Their theories
cover cognitive development, personality
development, and social development, respectively,
7KH,QWHJUDWLYH6FLHQFHRI0HQWDO,OOQHVV
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Progress in understanding depression and schizophrenia offers exciting examples of how findings
from different disciplines of the mental health field
have many common threads (Andreasen, 1997).
Despite the differences in terminology and
methodology, the results from different disciplines
have converged to paint a vivid picture of the
nature of the fundamental defects and the regions
of the brain that underlie these defects. Even in the
case of depression and schizophrenia, there is much
57
10
11
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Epigenetic influences are those that arise from outside the genes
and lead to emergent, as opposed to predetermined, properties.
58
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Theories of human development are grounded in
the developmental perspective. The developmental
perspective takes into account the biological,
social, and psychological environment; their
interaction; and their combined effect upon the
individual throughout the life span.
Developmentalist L. Breger (1974) proposes that
the developmental perspective incorporates three
key precepts:
Behavioral maturation proceeds from the
&
simple to the complex;
Future behaviors, whether temporally near or
&
distant, are a product of their antecedents (prior
responses to the developmental environment);
and
The human response to a particular event or
&
experience often depends on the developmental
stage at which the experience occurs.
Each of these precepts is thought to apply to
neurobiological development, as well as behavioral/psychosocial development. Moreover, each
has implications for whether an individual
experiences either healthful or unhealthful
development that may lead to a mental disorder.
The three precepts are at the heart of each of
the three major mainstream theories of
developmental psychology that have guided
research and increased our understanding of both
normal and abnormal human development across
the life span. The following paragraphs offer brief
59
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For over a century, an intense debate among
developmentalists and other scientists has pitted
nature (genetic inheritance) against nurture
(environment) as the engine of human development
and behavior. Francis Galton, a 19th-century
geneticist and cousin of Charles Darwin, declared
that there is no escape from the conclusion that
nature prevails enormously over nurture (cited in
Plomin, 1996). As the debate raged, either nature or
nurture gained ascendancy. During the 1940s and
1950s, for example, behaviorism held sway over
American psychology with its argument that
nurture was preeminent.
The pendulum now is coming to rest with the
recognition that behavior is the product of both
nature and nurture (Plomin, 1996). Each
contributes to the development of mental health and
mental illness. Nature and nurture are not
necessarily independent forces but can interact with
60
61
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The field of public health has long recognized the
imperative of prevention to contain a major health
problem (IOM, 1988). The principles of prevention were first applied to infectious diseases in
the form of mass vaccination, water safety, and
other forms of public hygiene. As successes
amassed, prevention came to be applied to other
areas of health, including chronic diseases (IOM,
1994a). A landmark report published by the
Institute of Medicine in 1994 extended the concept
of prevention to mental disorders (IOM, 1994a).
Reducing Risks for Mental Disorders evaluated the
body of research on the prevention of mental
disorders, offered new definitions of prevention,
and provided recommendations on Federal policies
and programs, among other goals.
Preventing an illness from occurring is
inherently better than having to treat the illness
after its onset. In many areas of health, increased
understanding of etiology and the role of risk and
protective factors in the onset of health problems
has propelled prevention. In the mental health field,
however, progress has been slow because of two
fundamental and interrelated problems: for most
major mental disorders, there is insufficient
understanding about etiology and/or there is an
inability to alter the known etiology of a particular
disorder. While these have stymied the development of prevention interventions, some successful
strategies have emerged in the absence of a full
understanding of etiology.
'HILQLWLRQVRI3UHYHQWLRQ
The term prevention has different meanings to
different people. It also has different meanings to
different fields of health. The classic definitions
used in public health distinguish between primary
prevention, secondary prevention, and tertiary
prevention (Commission on Chronic Illness, 1957).
Primary prevention is the prevention of a disease
before it occurs; secondary prevention is the
prevention of recurrences or exacerbations of a
disease that already has been diagnosed; and
tertiary prevention is the reduction in the amount of
disability caused by a disease to achieve the highest
level of function.
The Institute of Medicine report on prevention
identified problems in applying these definitions to
the mental health field (IOM, 1994a). The problems
stemmed mostly from the difficulty of diagnosing
mental disorders and from shifts in the definitions
of mental disorders over time (see Diagnosis of
Mental Illness). Consequently, the Institute of
Medicine redefined prevention for the mental
health field in terms of three core activities:
prevention, treatment, and maintenance (IOM,
1994a). Prevention, according to the IOM report, is
similar to the classic concept of primary prevention
62
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The concepts of risk and protective factors, risk
reduction, and enhancement of protective factors
(also sometimes referred to as fostering resilience)
are central to most empirically based prevention
programs. Risk factors are those characteristics,
variables, or hazards that, if present for a given
individual, make it more likely that this individual,
rather than someone selected at random from the
general population, will develop a disorder
(Garmezy, 1983; Werner & Smith, 1992; IOM,
1994a). To qualify as a risk factor the variable must
antedate the onset of the disorder. Yet risk factors
are not static. They can change in relation to a
63
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Mental disorders are treatable, contrary to what
many think. 12 An armamentarium of efficacious
treatments is available to ameliorate symptoms. In
12
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66
owes its origins as a treatment to the clientcentered therapy that was originated by Carl
Rogers, and the theory can be traced to
philosophical roots beginning with the 19th century
philosopher, Soren Kierkegaard. The central focus
of humanistic therapy is the immediate experience
of the client. The emphasis is on the present and the
potential for future development rather than on the
past, and on immediate feelings rather than on
thoughts or behaviors. It is rooted in the everyday
subjective experience of the person seeking
assistance and is much less concerned with mental
illness than it is with human growth.
One critical aspect of humanistic treatment is
the relationship that is forged between the
therapist, who in some ways serves as a guide in an
exploration of self-discovery, and the client, who is
seeking greater knowledge of the self and an
expansion of inherent human potential. The focus
on the self and the search for self-awareness is akin
to psychodynamic psychotherapy, while the
emphasis on the present is more similar to behavior
therapy.
Although it is possible to describe distinctive
orientations to psychotherapy, as has been done
above, most psychotherapists describe themselves
as eclectic in their practice, rather than as adherents
to any single approach to treatment. As a result,
there is a growing development referred to as
psychotherapy integration (Wolfe & Goldfried,
1988). It strives to capture what is best about each
of the individual approaches. Psychotherapy
integration includes various attempts to look
beyond the confines of any single orientation but
rather to see what can be learned from other
perspectives. It is characterized by an openness to
various ways of integrating diverse theories and
techniques. Psychotherapy also should be modified
to be culturally sensitive to the needs of racial and
ethnic minorities (Acosta et al., 1982; Sue et al.,
1994; Lopez, in press).
The scientific evidence on efficacy presented in
this report, however, is focused primarily on
specific, standardized forms of psychotherapy.
67
3KDUPDFRORJLFDO7KHUDSLHV
body to produce therapeutic effects. Pharmacotherapies that act in similar ways are grouped
together into broad categories (e.g., stimulants,
antidepressants). Within each category are several
chemical classes. The individual pharmacotherapies
within a chemical class share similar chemical
structures. Table 2-9 presents several common
categories and classes, along with their indication,
that is, their clinical use.
Many pharmacotherapies for mental disorders
have as their initial action the alterationeither
increase or decreasein the amount of a
neurotransmitter. Neurotransmitter levels can be
altered by pharmacotherapies in myriad ways:
pharmacotherapies can mimic the action of the
neurotransmitter in cell-to-cell signaling; they can
block the action of the neurotransmitter; or they
can alter its synthesis, breakdown (degradation),
release, or reuptake, among other possibilities
(Cooper et al., 1996).
Neurotransmitters generally are concentrated in
separate brain regions and circuits. Within the cells
that form a circuit, each neurotransmitter has its
own biochemical pathway for synthesis,
degradation, and reuptake, as well as its own
specialized molecules known as receptors. At the
time of neurotransmission, when a traveling signal
reaches the tip (terminal) of the presynaptic cell,
the neurotransmitter is released from the cell into
the synaptic cleft. It migrates across the synaptic
cleft in less than a millisecond and then binds to
receptors situated on the membrane of the
postsynaptic cell. The neurotransmitters binding to
the receptor alters the shape of the receptor in such
a way that the neurotransmitter can either excite the
postsynaptic cell, and thereby transmit the signal to
this next cell, or inhibit the receptor, and thereby
block signal transmission. The neurotransmitters
action is terminated either by enzymes that degrade
it right there, in the synaptic cleft, or by transporter
proteins that return unused neurotransmitter back to
the presynaptic neuron for reuse, a recycling
process known as reuptake. The widely prescribed
class of antidepressants referred to as the selective
68
Antipsychotics (neuroleptics)
Typical antipsychotics*
Atypical antipsychotics**
Schizophrenia, psychosis
Antidepressants
Selective serotonin
reuptake inhibitors
Tricyclic and heterocyclic
antidepressants***
Monoamine oxidase inhibitors
Depression, anxiety
Stimulants
Attention-deficit/hyperactivity disorder
Antimanic
Lithium
Anticonvulsants
Thyroid supplementation
Mania
Antianxiety (anxiolytics)
Benzodiazepines
Antidepressants
-Adrenergic-blocking drugs
Anxiety
Cholinesterase inhibitors
Alzheimers disease
* Also known as first-generation antipsychotics, they include these chemical classes: phenothiazines (e.g., chlorpromazine),
butyrophenones (e.g., haloperidol), and thioxanthenes (Dixon et al., 1995).
** Also known as second-generation antipsychotics, they include these chemical classes: dibenzoxazepine (e.g., clozapine),
thienobenzodiazepine (e.g., olanzapine), and benzisoxazole (e.g., risperidone).
*** Include imipramine and amitriptyline.
Source: Perry et al., 1997
69
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The foregoing section has furnished an overview of
the types and nature of mental health treatment.
The resounding message, which is echoed
throughout this report, is that a range of efficacious
treatments is available. The following material
deals with four issues surrounding treatmentthe
placebo response, benefits and risks, the gap between how well treatments work in clinical trials
versus in the real world, and the constellation of
barriers that hinder people from seeking mental
health treatment.
3ODFHER 5HVSRQVH
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17
16
71
18
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73
includes brief treatment-oriented services. Longterm care includes residential care as well as some
treatment services. Residential care is often
referred to as custodial, when supervised living
predominates over active treatment.
The settings for care and treatment include
institutional, community-based, and home-based.
The former refers to facilities, particularly public
mental hospitals and nursing homes, which usually
are seen by patients and families as large,
regimented, and impersonal. They often are
removed from the community by distance and
frequency of contact with friends and family. In
contrast, community-based services are close to
where patients or clients live. Services are typically
provided by community agencies and organizations.
Home-based services include informal supports
provided in an individuals residence.
74
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The history of mental health services in the United
States has been chronicled by historian Gerald N.
Grob in a series of landmark books from which this
account is drawn (Grob, 1983, 1991, 1994). The
origins of the mental health services system
coincide with the colonial settlement of the United
States. Individuals with mental illness were cared
for at home until urbanization induced state
governments to confront a problem that had been
relegated largely to families. The states response
was to build institutions, known first as asylums
and later as mental hospitals. When the
Pennsylvania Hospital opened in Philadelphia in
the mid-18th century, it had provisions for
individuals with mental illness housed in its
basement. Also in the mid-18th century, colonial
Virginia was the first state to build an asylum for
mentally ill citizens, which it constructed in its
capital at Williamsburg. If not cared for at home or
in asylums, those with mental illness were likely to
be found in jails, almshouses, work houses, and
other institutions. By the time of the Revolutionary
War, the beginnings were in place for each of the
four sectors of the de facto mental health system.
The origins of treatment for mental illness in
the general medical/primary care sector can be
traced to the Pennsylvania Hospital. The origins of
specialty mental health care can be traced to the
Williamsburg asylum. Home care, the most
common response to mental illness, probably
became a part of the voluntary support network,
whereas the human services sector was by far the
most common organized or institutional response,
by placing individuals in almshouses (homes for
the poor) and work houses. The first form of treatmentknown as moral treatmentwas not given
until the very end of the 18th century, after the
Revolutionary War.
2YHUDOO3DWWHUQVRI8VH
According to recent national surveys (Regier et al,
1993b; Kessler et al., 1996), a total of about 15
percent of the U.S. adult population use mental
health services in any given year. Eleven percent
receive their services from either the general
medical care sector or the specialty mental health
sector, in roughly equal proportions. In addition,
about 5 percent receive care from the human
services sector, and about 3 percent receive care
from the voluntary support network. (The overlap
across these latter two sectors accounts for these
figures totaling more than 15 percent.)
Slightly more than half of the 15 percent of the
adult population that use mental health services
have a diagnosable mental or addictive disorder (8
percent), while the remaining portion has a mental
health problem (7 percent). Bearing in mind that 28
percent of the population have a diagnosable
mental or substance abuse disorder, only about
one-third with a diagnosable mental disorder
receives treatment in 1 year (Figure 2-5). In short,
this translates to the majority of those with
a diagnosable mental disorder not receiving
treatment.
Similarly, about 21 percent of the child and
adolescent population use mental health services
annually. Nine percent receive care from the health
care sector, almost exclusively from the specialty
mental health sector. Seventeen percent of the child
and adolescent population receive care from the
human services sector, mostly in the school system,
yet there is much overlap with the health sector
(again accounting for the sum being more than 21
75
76
77
78
Table 2-10. Historical reform movements in mental health treatment in the United States
Reform Movement
Era
Setting
Focus of Reform
Moral Treatment
1800%1850
Asylum
Mental Hygiene
1890%1920
Prevention, scientific
orientation
1955%1970
Deinstitutionalization,
social integration
Community support
Community Support
1975%present
79
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The U.S. mental health system is not well equipped
to meet the needs of racial and ethnic minority
populations. Racial and ethnic minority groups are
generally considered to be underserved by the
mental health services system (Neighbors et al.,
1992; Takeuchi & Uehara, 1996; Center for Mental
Health Services [CMHS], 1998). A constellation of
barriers deters ethnic and racial minority group
members from seeking treatment, and if individual
members of groups succeed in accessing services,
their treatment may be inappropriate to meet their
needs.
Awareness of the problem dates back to the
1960s and 1970s, with the rise of the civil rights
and community mental health movements (Rogler
et al., 1987) and with successive waves of
immigration from Central America, the Caribbean,
and Asia (Takeuchi & Uehara, 1996). These
historical forces spurred greater recognition of the
problems that minority groups confront in relation
to mental health services.
Research documents that many members of
minority groups fear, or feel ill at ease with, the
mental health system (Lin et al., 1982; Sussman et
al., 1987; Scheffler & Miller, 1991). These groups
experience it as the product of white, European
80
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The Federal government officially designates four
major racial or ethnic minority groups in the United
States: African American (black), Asian/Pacific
Islander, Hispanic American (Latino), 20 and Native
American/American Indian/Alaska Native/Native
Hawaiian (referred to subsequently as American
Indians) (CMHS, 1998). There are many other
21
20
22
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Ties to family and community, especially strong in
African, Latino, Asian, and Native American
communities, are forged by cultural tradition and
by the current and historical need to assist arriving
immigrants, to provide a sanctuary against
discrimination practiced by the larger society, and
to provide a sense of belonging and affirming a
centrally held cultural or ethnic identity.
Among Mexican-Americans (del Pinal &
Singer, 1997) and Asian Americans (Lee, 1998)
relatively high rates of marriage and low rates of
divorce, along with a greater tendency to live in
extended family households, indicate an orientation
toward family. Family solidarity has been invoked
to explain relatively low rates among minority
groups of placing older people in nursing homes
(Short et al., 1994).
The relative economic success of Chinese,
Japanese, and Korean Americans has been
attributed to family and communal bonds of
association (Fukuyama, 1995). Community
organizations and networks established in the
United States include rotating credit associations
based on lineage, surname, or region of origin.
These organizations and networks facilitate the
startup of small businesses.
There is evidence of an African American
tradition of voluntary organizations and clubs often
having political, economic, and social functions
and affiliation with religious organizations
(Milburn & Bowman, 1991). African Americans
83
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The prevalence of mental disorders is estimated to
be higher among African Americans than among
whites (Regier et al., 1993a). This difference does
not appear to be due to intrinsic differences
between the races; rather, it appears to be due to
socioeconomic differences. When socioeconomic
factors are taken into account, the prevalence
difference disappears. That is, the socioeconomic
status-adjusted rates of mental disorder among
African Americans turn out to be the same as those
of whites. In other words, it is the lower
socioeconomic status of African Americans that
places them at higher risk for mental disorders
(Regier et al., 1993a).
African Americans are underrepresented in
some outpatient treatment populations, but overrepresented in public inpatient psychiatric care in
relation to whites (Snowden & Cheung, 1990;
24
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The underrepresentation in outpatient treatment of
racial and ethnic minority groups appears to be the
result of cultural differences as well as financial,
organizational, and diagnostic factors. The service
system has not been designed to respond to the
cultural and linguistic needs presented by many
racial and ethnic minorities. What is unresolved are
the relative contribution and significance of each
factor for distinct minority groups.
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The previous paragraphs have documented
underutilization of treatment, less help-seeking
behavior, inappropriate diagnosis, and other
problems that have beset racial and ethnic minority
groups with respect to mental health treatment.
This kind of evidence has fueled the widespread
perception of mental health treatment as being
uninviting, inappropriate, or not as effective for
minority groups as for whites. The Schizophrenia
Patient Outcome Research Team demonstrated that
88
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The differences between rural and urban communities present another source of diversity in mental
health services. People in rural America encounter
numerous barriers to the receipt of effective
services. Some barriers are geographic, created by
the problem of delivering services in less densely
populated rural areas and even more sparsely
populated frontier areas. Some barriers are
cultural, insofar as rural America reflects a range
of cultures and life styles that are distinct from
urban life. Urban culture and its approach to
delivering mental health services dominate mental
health services (Beeson et al., 1998).
Rural America is shrinking in size and political
influence (Danbom, 1995; Dyer, 1997). As a
consequence, rural mental health services do not
figure prominently in mental health policy (Ahr &
Holcomb, 1985; Kimmel, 1992). Furthermore, rural
economies are in decline, and the population is
decreasing in most areas (yet expanding rapidly in
a few boom areas) (Hannan, 1998). Rural America
is no longer a stable or homogeneous environment.
The farm crisis of the 1980s unleashed a period of
economic hardship and rapid social change,
adversely affecting the mental health of the
population (Ortega et al., 1994; Hoyt et al., 1995).
Policies and programs designed for urban
mental health services often are not appropriate for
rural mental health services (Beeson et al., 1998).
Beeson and his colleagues (1998) list a host of
important differences that should be considered in
designing rural mental health services. In an era of
specialized services, rural mental health relies
heavily on primary medical care and social
services. Stigma is particularly intense in rural
communities, where anonymity is difficult to
maintain (Hoyt et al., 1997). In an era of expanding
private mental health services, rural mental health
services have been predominantly publicly funded.
Consumer and family involvement in advocacy,
characteristic of urban and suburban areas, is rare
in rural America. The supply of services and
providers is limited, so choice is constrained.
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Since the late 1970s, mental health services
continue to be transformed by the growing
influence of consumer and family organizations
(Lefley, 1996). Through strong advocacy, consumer
and family organizations have gained a voice in
legislation and policy for mental health service
delivery. Organizations representing consumers and
family members, though divergent in their
historical origins and philosophy, have developed
some important, overlapping goals: overcoming
stigma and preventing discrimination, promoting
self-help groups, and promoting recovery from
mental illness (Frese, 1998).
This section covers the history, goals, and
impact of consumer and family organizations,
whereas the next section covers the process of
recovery from mental illness. With literally
hundreds of grassroots consumer organizations
across the United States, no single organization
92
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The consumer movement arose as a protest in the
1970s by former patients of mental hospitals. Their
antecedents trace back to the 19th century, when a
handful of individuals recovered enough to write
exposs expressing their outrage at the indignities
and abuses inside mental hospitals. The most
persuasive former patient was Clifford Beers,
whose classic book, A Mind That Found Itself
(1908), galvanized the mental hygiene reform
movement (Grob, 1994). Beers was among the
founders of the National Committee on Mental
Hygiene, an advocacy group that later was renamed
the National Mental Health Association. This group
focuses on linking citizens and mental health
professionals in broad-based prevention of mental
illness.
With the advent of deinstitutionalization in the
1950s, increasing numbers of former patients of
mental hospitals began to forge informal ties in the
community. By the 1960s, the civil rights movement inspired former patients to become better
organized into what was then coined the mental
patients liberation movement (Chamberlin, 1995).
93
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The family movement has experienced spectacular
growth and influence since its beginnings in the
late 1970s (Lefley, 1996). Although several
advocacy and professional organizations speak to
the needs of families, the family movement is
principal l y r epr es ented by three large
organizations. They are the National Alliance for
the Mentally Ill (NAMI), the Federation of Families
for Childrens Mental Health (FFCMH), and the
National Mental Health Association (NMHA).
NAMI serves families of adults with chronic mental
illness, whereas the Federation serves children and
youth with emotional, behavioral, or mental
disorders. NMHA serves a broad base of family
members and other supporters of children and
adults with mental disorders and mental health
problems. Though the target populations are
different, these organizations are similar in their
devotion to advocacy, family support, research, and
public awareness.
Fragmentation and lack of availability of
services were motivating forces behind the
establishment of the family movement.
Deinstitutionalization, in particular, was a cogent
impetus f o r t h e f o r ma t i on of NAMI.
Deinstitutionalization of the mentally ill left
families in the unexpected position of having to
assume care for their adult children, a role for
which they were ill prepared. Another motivating
force behind the family movement was the past
tendency by the mental health establishment to
blame parents for the mental illness in children
(Frese, 1998). The cause of schizophrenia, for
example, h a d b e e n a t t r ibuted to the
schizophrenogenic mother, who was cold and
aloof, according to a reigning but now discredited
view of etiology. Similarly, parents were viewed as
partly to blame for children with serious emotional
or behavioral disturbances (Melaville & Asayesh
1993; Friesen & Stephens, 1998).
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Recovery is a concept introduced in the lay
writings of consumers beginning in the 1980s. It
was inspired by consumers who had themselves
recovered to the extent that they were able to write
about their experiences of coping with symptoms,
getting better, and gaining an identity (Deegan,
1988; Leete, 1989). Recovery also was fueled by
longitudinal research uncovering a more positive
course for a significant number of patients with
severe mental illness (Harding et al., 1992),
although findings across several studies were
variable (Harrow et al., 1997) (see discussion in
Chapter 4).
Recovery is variously called a process, an
outlook, a vision, a guiding principle. There is
neither a single agreed-upon definition of recovery
nor a single way to measure it. But the overarching
message is that hope and restoration of a
meaningful life are possible, despite serious mental
illness (Deegan, 1988; Anthony, 1993; Stocks,
1995; Spaniol et al., 1997). Instead of focusing
primarily on symptom relief, as the medical model
dictates, recovery casts a much wider spotlight on
restoration of self-esteem and identity and on
attaining meaningful roles in society.
Written testimonials by former mental patients
have appeared for centuries. These writings,
according to historian of medicine Roy Porter,
shore up that sense of personhood and identity
which they feel is eroded by society and
psychiatry (Porter, 1987). What distinguishes the
contemporary wave of writings is their critical
mass, organizational backing, and freedom of
2YHUYLHZRI5HFRYHU\
Until recently, some severe mental disorders were
generally considered to be marked by lifelong
deterioration. Schizophrenia, for instance, was seen
by the mental health profession as having a
uniformly downhill course (Harding et al., 1992).
At the beginning of the 20th century, the leading
psychiatrist of the era, Emil Kraepelin, judged the
outcome of schizophrenia to be so dismal that he
named the disorder dementia praecox, or
premature dementia. Negative conceptions of
severe mental illness, perpetuated in textbooks for
decades by Kraepelins original writings, dampened
consumers and families expectations, leaving
them without hope. A turnabout in attitudes came
as a result of the consumer movement and self-help
activities. They mobilized a shift toward a more
positive set of consumer attitudes and selfperceptions. Research provided a scientific basis
for and supported a more optimistic view of the
97
,PSDFWRIWKH5HFRYHU\&RQFHSW
The impact of the recovery concept is felt most by
consumers and families. Consumers and families
are energized by the message of hope and selfdetermination. Having more active roles in
98
99
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The past 25 years have been marked by several
discrete, defining trends in the mental health field.
These have included:
1. The extraordinary pace and productivity of
scientific research on the brain and behavior;
2. The introduction of a range of effective
treatments for most mental disorders;
3. A dramatic transformation of our societys
approaches to the organization and financing of
mental health care; and
4. The emergence of powerful consumer and
family movements.
Scientific Research. The brain has emerged as
the central focus for studies of mental health and
mental illness. New scientific disciplines,
technologies, and insights have begun to weave a
seamless picture of the way in which the brain
mediates the influence of biological, psychological,
and social factors on human thought, behavior, and
emotion in health and in illness. Molecular and
cellular biology and molecular genetics, which are
complemented by sophisticated cognitive and
behavioral science, are preeminent research
disciplines in the contemporary neuroscience of
mental health. These disciplines are affording
unprecedented opportunities for bottom-up
studies of the brain. This term refers to research
that is examining the workings of the brain at the
most fundamental levels. Studies focus, for
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WKH/LIHVSDQ
The Surgeon Generals report takes a lifespan
approach to its consideration of mental health and
mental illness. Three chapters that address,
respectively, the periods of childhood and
adolescence, adulthood, and later adult life
beginning somewhere between ages 55 and 65,
capture the contributions of research to the breadth,
depth, and vibrancy that characterize all facets of
the contemporary mental health field.
The disorders featured in depth in Chapters 3,
4, and 5 were selected on the basis of the frequency
with which they occur in our society, and the
clinical, societal, and economic burden associated
with each. To the extent that data permit, the report
takes note of how gender and culture, in addition to
age, influence the diagnosis, course, and treatment
of mental illness. The chapters also note the
changing role of consumers and families, with
attention to informal support services (i.e., unpaid
services), with which many consumers are
comfortable and upon which they depend for
information. Persons with mental illness and, often,
their families welcome a proliferating array of
support servicessuch as self-help programs,
family self-help, crisis services, and advocacy
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Acosta, F. X., Yamamoto, J., & Evans, L. A. (1982).
Effective psychotherapy for low-income and
minority patients. New York: Plenum Press.
Ahr, P. R., & Holcomb, W. R. (1985). State mental
health directors priorities for mental health care.
Hospital and Community Psychiatry, 36, 3945.
American Psychiatric Association. (1952). Diagnostic
and statistical manual of mental disorders (1st ed.).
Washington, DC: Author.
American Psychiatric Association. (1968). Diagnostic
and statistical manual of mental disorders (2nd
ed.). Washington, DC: Author.
American Psychiatric Association. (1980). Diagnostic
and statistical manual of mental disorders (3rd ed.).
Washington, DC: Author.
American Psychiatric Association. (1987). Diagnostic
and statistical manual of mental disorders (3rd
ed.rev.). Washington, DC: Author.
American Psychiatric Association. (1994). Diagnostic
and statistical manual of mental disorders (4th ed.).
Washington, DC: Author.
Andreasen, N. C. (1997). Linking mind and brain in the
study of mental illnesses: A project for a scientific
psychopathology. Science, 275, 15861593.
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